Gombe State Framework for the Implementation of Expanded Access to Family Planning Services 2013‒2018

Home , Billiri, Dukku, Funakaye, Gombe State, Kwami, Nafada

Gombe State Framework for the Implementation of Expanded Access to Family Planning Services 2013-2018

December 2012

Gombe State Framework for the Implementation of Expanded Access to Family Planning Services 2013-2018

December 2012

The Gombe State Framework for the Implementation of Expanded Access to Family Planning Services 2013 2018 was developed by the Gombe State Ministry of Health in July 2012. Financial Assistance for the framework was provided by the U.S. Agency for International Development (USAID) under the terms of the‒ Cooperative Agreement GPO – A-00-08-00001-00 through FHI 360’s Program Research for Strengthening Services (PROGRESS) project. The contents of this publication do not necessarily reflect the views of USAID or the U.S. government.

This publication may be freely reviewed, quoted, reproduced or translated, in full or in part, provided the source is acknowledged.

First published in 2012 by the Gombe State Ministry of Health, Nigeria, with support from USAID– PROGRESS

Citation: Gombe State Ministry of Health (SMoH). 2012. Gombe state framework for the implementation of expanded access to family planning services. Gombe (Nigeria): SMoH; 2012 Dec.

TABLE OF CONTENTS

LE OF CONTENTS Table of contents ...... 1 Foreword ...... 3 Acknowledgements ...... 4 Acronyms ...... 5 Executive Summary ...... 7 Introduction ...... 9 1.1 Family Planning in Nigeria ...... 9 1.2 Family Planning in Gombe State ...... 10 1.3 Rationale for Expanding Community and Facility-based FP Service Delivery ...... 11 Methodology for Creating the Implementation Framework ...... 13 Goals, Objectives and Strategic Intervention Areas ...... 15 3.1 Goal ...... 15 3.2 Objectives and Targets ...... 16 3.3 Eight Strategic Intervention Areas ...... 18 3.4 Benefits and Impact of Expanded Family Planning Service Delivery ...... 20 Plan of Action...... 21 4.1 Objective 1 ...... 21 4.2 Objective 2 ...... 31 4.3 Objective 3 ...... 38 4.4 Objective 4 ...... 43 Budget Summary ...... 46 Appendix 1. Calculation Justifications and Assumptions ...... 47 Appendix 2. Summary of Stakeholder Analysis ...... 53 Appendix 3. Participation List: CBA TWG Meeting Convened September 21 22, 2011, on the Road Map for Scaling Up Community-Based Access to Family Planning Focused on Injectables in Nigeria ...... ‒ ...... 56 Appendix 4. Participation List: Planning Meeting Convened July 18 20, 2012, on the Gombe State Framework for the Implementation of Expanded Access to Family Planning Services Framework ‒ 2013 2018 ...... 58

Appendix‒ 5. Participation List: Review Meeting held October 4, 2012, on the Gombe State Framework for the Implementation of Expanded Access to Family Planning Services Framework 2013 2018 ...... 59

Appendix‒ 6. WHO Health System Framework ...... 61 References ...... 62 Other Resources...... 63

Tables and Figures

Figure 1: Trends in unmet family planning needs by area of residence: 1990, 1999, 2003 and 2008 ..... 9 Figure 2: Trends in modern contraceptive prevalence in Nigeria by zone: 1999, 2003 and 2008 ...... 10 Figure 3: Distribution of health personnel working in Gombe state by cadre ...... 11 Figure 4: Goals, objectives and strategic areas of intervention ...... 15 Table 1: Annual Progression towards Targets by Objective ...... 17 Table 2: Family Planning Impact Indicators...... 20 Table A1.1. Number of Health Personnel Providing FP and Training in FP ...... 47 Table A1.2. Clinicians Required by Base Year ...... 48 Table A1.3. Number of Wards with Access to CBFP and Health Facilities Providing FP ...... 48 Table A1.4. Requirements to Reach CPR Goal — Number of FP Users, Number of Commodities, Cost for Commodities and Logistics, Percent of Users by Method ...... 49 Table A1.5. Commodity Costs (US$) ...... 51 Table A1.6. FP Support by Men, Women, Youth, Community Leaders and Policymakers ...... 51 Table A1.7. Family Planning Impact Indicators...... 52

2 FOREWORD Family planning saves lives. Family planning prevents up to one third of maternal deaths and can reduce child mortality. In many states in Nigeria, including Gombe state, many women still die from childbirth. Infant and child mortality rates remain high. Most women have an average of seven children in their lifetime while the use of family planning services remains low. The shortage of skilled health care workers and a weak distribution chain have contributed to limited access to family planning services in rural areas.

To address these challenges, the Gombe state government developed the Gombe State Framework for the Implementation of Expanded Access to Family Planning Services 2013–2018. This framework builds on previous family planning efforts in Gombe state, particularly the 2008–2010 community-based access to injectable contraceptives pilot implemented in two local government areas. The pilot, implemented by the Association of Reproductive and Family Health (ARFH) and FHI 360 (formerly Family Health International), with funding from the U.S. Agency for International Development (USAID), demonstrated that community health extension workers could safely provide injectable contraceptives at the community level. This pilot provided the evidence for policy change.

The framework will ensure universal access to modern family planning methods across the state. This expansion framework identifies an overarching family planning goal, objectives, strategic intervention areas and key activities required to guide the scale-up of quality family planning services by all cadres of health workers at all service delivery levels across Gombe state.

This framework’s success will depend on commitments made and fulfilled by relevant stakeholders, including the federal government, Gombe state government, donors, implementing partners, civil society nongovernmental organizations, religious and traditional leaders, the private sector and the citizens of Gombe state. Stakeholders will play a role in funding, organizing, managing and evaluating the framework.

It is my hope that the Gombe State Framework for the Implementation of Expanded Access to Family Planning Services 2013 2018 will contribute to Gombe state’s Millennium Development Goals 4 and 5 to reduce maternal child mortality and morbidity. I therefore encourage all stakeholders to support the endorsement of ‒ this framework.

Kennedy Ishaya, MD Honourable Commissioner Ministry of Health Gombe State

3 ACKNOWLEDGEMENTS First, our sincere gratitude goes to the Almighty God who made it possible for us to achieve the feat of completing the Gombe State Framework for the Implementation of Expanded Access to Family Planning Services 2013 2018.

We thank‒ the Honourable Commissioner of Health, the Permanent Secretary and our Director of Primary Health Care for all their advice and support.

We are equally grateful to all other line ministries who supported the framework’s development. In particular, the Ministry of Economic and Budget Planning which made development possible through a concerted approach and efforts to have this framework finalized.

We register our special appreciation to FHI 360, who has been on the front line of all community-based access to family planning activities in Gombe state, for their unflinching support since the era of the pilot project through the post-pilot phase and now in developing our capacity to scale up the project.

Our special thanks also goes to participating organizations, including the World Health Organization (WHO), the United Nations Children’s Fund (UNICEF), Management Services for Health (MSH), Pact Nigeria, Save the Children and the Targeted States High Impact Project (TSHIP) led by John Snow, Inc. (JSI). We thank all our other development and commercial partners who worked very hard with us to make sure the framework development became a reality.

We also thank USAID for funding support that created a catalyst for implementing the project. We are also grateful for the commitment from FHI 360 as well as the consultant working on the project, Dr. Nnena Mba-Oduwusi. Their commitment to the process encouraged us to develop this framework for expanding access to family planning.

Finally, we commend the efforts of all those who participated in the 55th National Council of Health (NCH) held July 16–20, 2012, which led to a task sharing policy change to allow community health extension workers to provide injectable contraceptives as part of their extension services.

Alhaji Umaru Gurama

Permanent Secretary

Ministry of Health

Gombe

4 ACRONYMS

AGMPN Association of General & Private Medical Practitioners of Nigeria AIDS Acquired immune deficiency syndrome APHPN Association of Public Health Practitioners of Nigeria ARFH Association of Reproductive and Family Health B4H Brothers for Health BP Blood Pressure CB Community-based CBA Community-based access CBA TWG Community-Based Access Technical Working Group CBD Community-based distribution CBOs Community-based organizations CHEW Community health extension worker CHO Community health officer CHPRBN Community Health Practitioners Registration Board of Nigeria CLMS Commodities and logistics management system CPR Contraceptive prevalence rate CS Contraceptive services CSOs Civil society organizations CYP Couple years of protection DPHC Director of Primary Health Care FGD Focus group discussion FLE Family life education FLHE Family life and HIV education FMoH Federal Ministry of Health FP Family planning GATHER Greet, Ask, Tell, Help, Explain, and Return HF Health facility HIV Human immunodeficiency virus HMB Hospital Management Board IUCD Intrauterine contraceptive device JCHEW Junior community health extension worker JSI John Snow Inc. LAPM Long acting and permanent methods LGAs Local government areas LGSC Local Government Service Commission LMIS Logistics management information system LOE Level of effort M&E Monitoring and evaluation MCH Maternal and child health MDCN Medical and Dental Council of Nigeria MDG Millennium Development Goal MEC Medical eligibility criteria MNCH Maternal newborn and child health MoH Ministry of Health

5 MoYD Ministry of Youth Development MoE Ministry of Education MoEP Ministry of Economic Planning MoF Ministry of Finance MSH Management Services for Health MSS Midwifery service scheme MVA Manual vacuum aspiration NCH National Council of Health NDHS National Demographic Health Survey NGOs Nongovernmental organizations NHMIS National Health Management Information System NID National Immunization Days NMA Nigeria Medical Association NMCN Nursing and Midwifery Council of Nigeria NPPSD National Policy on Population for Sustainable Development NURHI Nigeria Urban Reproductive Health Initiative PAC Post abortion care PAFP Post abortion family planning PHC Primary health center PPFP Post-partum family planning PPFN Planned Parenthood Federation of Nigeria PROGRESS Program Research for Strengthening Services QIT Quality improvement team RH Reproductive health RH TWG Reproductive Health Technical Working Group S4H Sisters for Health SACA State Agency for Control of AIDS SASCP State AIDS and STI Control Programme SMO Social Mobilization Officer SMoE State Ministry of Education SMoEP State Ministry of Economic Planning SMoH State Ministry of Health SMoLGA State Ministry of Local Government Affairs SMWASD State Ministry of Women and Social Development SOP Standard operating procedure SSHDP State Strategic Health Development Plan SSMO State social mobilization officer TFR Total fertility rate TSHIP Targeted States High Impact Project TWG Technical working group UNFPA United Nations Population Fund USAID U.S. Agency for International Development VDCs Village development committee WDCs Ward development committee WHO World Health Organization

EXECUTIVE SUMMARY It was in this context that the Gombe State Ministry of Health (SMoH), with technical assistance from FHI 360 through funding from Prompt access to effective family USAID, developed this document, the Gombe State planning (FP) is one of the major Framework for the Implementation of Expanded Access to strategies for improving maternal Family Planning Services 2013–2018. This document and child health and is an avenue for was developed to guide the rollout of increased FP services at the community and facility levels promoting national development. and at a wider state level to accelerate efforts to Universal access, as stipulated in the achieve the state and national development goals Maputo Plan of Action, means the and the Millennium Development Goals (MDGs). ability to have health services at The SMoH will be the overall coordinating agency affordable costs as near to the and work closely with the LGAs with support people as possible. from partners.

But according to the latest (2008) Nigeria Demographic and Health Survey2, only 9.7 percent of married women of reproductive age The framework includes a goal, four objectives, nationwide use a modern contraceptive method targets and activities. The goal is to improve and far fewer women in Gombe (5.3 percent).This access to and uptake of FP methods in Gombe low contraceptive uptake has contributed to state such that the contraceptive prevalence rate Gombe state having some of the lowest maternal (CPR) increases to 22.1 percent in 2018. This CPR and reproductive health indices among women goal is based on a projected baseline CPR of 8.82 and children in Nigeria. percent in 2012 (see Appendix 1). The framework’s four objectives are to:

A 2008 task sharing pilot project implemented by FHI 360 and the Association for Reproductive 1. Build the capacity of all CHEWs, doctors, and Family Health (ARFH) attempted to bridge nurses and midwives working in the human resource and policy barriers to FP reproductive health (RH) and FP to provision in Funakaye and Yamaltu Deba local provide cadre-appropriate FP services in Gombe state by 2018. government areas (LGAs) of Gombe state. The project, which ended in 2010, demonstrated that 2. Expand the availability of FP community health extension workers (CHEWs) commodities offered by cadre-appropriate providers in the wards, primary health could safely and effectively administer injectable centres, and secondary and tertiary contraceptives with minimal supervision.1 facilities in Gombe state by 2018. Findings from this pilot provided evidence 3. Increase the use of FP methods among required by the National Council of Health in men, women and young persons of 2012 to decide to change policy and allow reproductive age in Gombe state by 2018. CHEWs to provide injectable contraceptives at Increase the level of state and community the community level to increase access to FP for 4. support for FP services in Gombe state women in hard-to-reach areas. by 2018.

7 The first two objectives will strengthen the supply The framework also includes a “Plan of Action” side of FP, whereas the last two objectives will that describes activities for each strategic ensure a supportive environment for increased intervention area, stakeholders responsible and demand and uptake of contraceptive methods. costs. This “Plan of Action” offers defined Each objective has specific targets or indicators opportunities for donors or partners to support and related activities that address eight strategic the state government and public sector workers to interventions areas identified by a national provide quality FP services. community-based access (CBA) technical working group (TWG). The strategic intervention areas for the activities include the following: When implemented, this framework will ensure 1. Advocacy and social mobilization for an that women, men and youth have increased access enabling environment to support FP to a broader FP method mix at the community 2. Training and capacity building and facility levels, more frontline health workers and clinicians are trained in FP and that the Service provision and supportive 3. overall support for FP among community leaders supervision and policymakers has improved. 4. Quality assurance 5. Commodities and logistics management 6. Finance and resource mobilization 7. Monitoring and reporting 8. Integration of FP with HIV/AIDS and maternal neonatal and child health (MNCH)

INTRODUCTION

1.1 Family Planning in Nigeria Reproductive health status in Nigeria has remained poor with only a marginal improvement over time as reflected in the high maternal 1 morbidity and mortality rate, high infant mortality rate, and low contraceptive prevalence rate.

Figure 1: Trends in unmet family planning needs by area of residence: 1990, 1999, 2003 and 2008

25 22 20.5 20.6

19.3 20 17.9 16.6 17.3 16.7 15 45 Urban - Rural 10 Aged 15 Aged 5 Among Maried Women Women Maried Among

Percentage of Unmet Need Need Unmet of Percentage 0 1990 1999 2003 2008

Source: NDHS: 1990, 1999, 2003 and 2008

Despite the knowledge of at least one contraceptive method by 72 percent of Nigerian women, the CPR for women who use any method (including traditional ones) is only 15 percent (and 9.7 percent for modern methods). This is one of the lowest such rates in Sub-Saharan Africa.2 There is a wide urban- rural disparity in contraceptive use and the CPR varies greatly by geopolitical zone with the northern zones (where Gombe state is located) having only marginally improved CPRs over the years compared to the southern zones (Figure 2). Similarly, the total fertility rate (TFR) of 5.7 births per woman has not changed since the findings in 2003.2

While the use of modern methods of contraception only marginally increased between 2003 and 2008 unmet need grew from 17% to 20% (Figure 1).2,3 Factors associated with this unmet need are varied, ranging from the unavailability of services to cultural or religious barriers, rural residence, and lack of knowledge about family planning.2,4 The shortage of skilled health care workers and a weak distribution chain further limits access to FP services.

Figure 2: Trends in modern contraceptive prevalence in Nigeria by zone: 1999, 2003 and 2008 25

15 1990 10 1999

5 2003 2008 0 North North East North West South East South South West National Central South Modern CPR

Source: NDHS 1990, 1999, 2003 and 2008

1.2 Family Planning in Gombe State

Gombe state is located in the predominately Muslim northeast geopolitical zone of Nigeria and has a population of 2.4 million. It was created on October 1, 1996, out of neighboring Bauchi state. It has a total fertility rate of 7.4 children per woman and a CPR for modern methods of 4.5 percent (see Table 1), both of which are worse than the national averages. In addition, the rural CPR (4.3 percent) is far higher than the urban rate (13 percent).5 Contraceptive use is also very low among adolescents and young adults, which has resulted in a high prevalence of undesired pregnancies, unsafe abortions and hence high abortion-related deaths.5 Gombe state has a high maternal mortality ratio of approximately 800 per 100,000 live births compared to 545 per 100,000 nationally and an under-5 mortality rate of 230 per 1,000 live births compared to 157 per 1,000 nationally.2 There have been very few far-reaching initiatives to improve FP. From 2003 to 2007 the United Nations Population Fund (UNFPA) supported the implementation of existing reproductive health (RH) policies at all levels and improved availability of RH commodities. But since that time, there have been no large-scale FP efforts.

The majority (89 percent) of health care facilities in Gombe state are administered by the state government, while 7 percent are considered federal government facilities and the remaining 4 percent are private. There are 579 health facilities in the state with 4,320 health care personnel employed (see Figure 3).5 The bulk of the health workforce in the state consist of lower cadre workers, such as CHEWs, junior

10 CHEWs (JCHEWS), environmental health officers, environmental health technicians and others. Most doctors in the state are employed by the Federal Medical Centre, which is located in the capital. Gombe state currently does not have a staff deployment policy, but those who are willing to work in high demand areas or rural settings are given incentives. Despite incentives, recruitment and retention problems persist.

Figure 3: Distribution of health personnel working in Gombe state by cadre

Doctors (163) VHW (181) 4% 4% Pharmacists (69) 1% TBA (260) 6%

EHOs/EHT/ Doctors (163) EHAs (560) Nurses/Midwives Pharmacists (69) 13% (1159) Nurses/Midwives (1159) 27% CHOs (114)

JCHEWs CHEWs (1209) (605) 14% JCHEWs (605)

EHOs/EHT/EHAs (560) CHEWs CHOs (1209) (114) TBA (260) 28% 3% VHW (181)

Source: Gombe SMoH, 2009

1.3 Rationale for Expanding Community and Facility-based FP Service Delivery

The Gombe state government identified the promotion of family planning as a key strategy for achieving the maternal and child health goals set forth in its State Strategic Health Development Plan 2010-2015.5 It was with this outlook that the state government and stakeholders agreed to have two LGAs serve as pilot sites for assessing the safety and effectiveness of CHEWs providing injectable contraceptives at the community-level as a way to increase FP access and uptake between 2008-2010.

Injectables are the most commonly used FP method among married women in the state and nationally but are almost exclusively accessed in health facilities2 because this method could not be provided at the community-level prior to the policy change in July 2012. FP clinic use in Nigeria is low,6 and complementing it with community-based access will be beneficial for many reasons. Access to FP services will be increased for people living in rural areas where distance to health facilities is a key barrier to accessing services. In addition, in a conservative state such as Gombe, women are expected to have their male partners’ permission before they use FP services. CBA allows women to access services in the privacy of their homes or the CHEW’s home to avoid the stigma attached to FP use that is still common in many communities.

11 In addition, to demonstrating the feasibility of this practice in a culturally conservative setting the pilot findings suggest that community-based access appears promising in reaching men with FP services and more efforts should focus on community-based approaches to reach men.1 The study showed that 13.9 percent of the clients who accessed FP services from community-based provision were males. Data were not available on the sex of all clients who accessed facility-based provision. But facility-based providers acknowledged that male clients do not normally access FP services in health facilities because such services are almost always provided in maternity clinics (including antenatal care, labour, postnatal care and family planning), which are patronized by women and children. Motivating men to attend FP clinics is difficult, so the proportion of males that accessed FP through CBA is encouraging.

In addition to CBFP service delivery, the SMoH also recognizes that facility-based service provision will need to be strengthened as well if FP access and uptake are to be increased. Facility-based providers, specifically the clinicians, will play a key role in providing long acting methods such as implants and IUDs that will substantially contribute to achieving the CPR goal. Therefore, the framework focuses on improving both community- and facility-based service delivery strategies.

12 METHODOLOGY FOR CREATING THE IMPLEMENTATION FRAMEWORK This framework was developed under the leadership of the Gombe SMoH and the Gombe State Reproductive Health 2 Technical Working Group (RH TWG) who referenced documents from the FMoH and the National CBA TWG. This section describes the series of meetings convened and activities implemented to draft and finalize the framework.

Community-Based Access Technical Working Group: The Road Map for Scaling Up Community-Based Access to Injectable Contraceptives In September 2011, the National Community-Based Access Technical Working Group (CBA TWG) was convened by the FMoH. The CBA TWG developed a road map to guide the scale-up of community- based access to FP which included eight strategic intervention areas that must be addressed to ensure successful expansion (see Appendix 3).7 Selection of these eight themes was influenced by the WHO Health System Framework’s six building blocks (see Appendix 6)8 and are therefore also applicable to strengthening facility as well as the community-based FP service delivery.

Baseline Assessment To better understand the FP situation in Gombe state, in May 2012, FHI 360 supported the Gombe state RH TWG to conduct a baseline assessment of the readiness and capacity of the health system to provide FP services. The Report of the Baseline Asessment of Community-based Access to Family Planning in Gombe State, North-East Nigeria (Gombe State Ministry of Health, 2012)9 used a simple random sample of two primary health care facilities from each of the 11 LGAs and a secondary facility for inclusion in the assessment. The examined components of the health system included the health workforce, service delivery, funding, commodities and logistics, supervision and health information system. Secondly, the FP knowledge, attitudes and practices among community leaders and men and women of reproductive age were also assessed using key informant interviews and focus group discussions. The results from this assessment informed several assumptions made in the framework and are noted where applicable.

Framework Planning Meeting A participatory planning session was conducted with representatives of the Gombe State MoH, Ministries of Economic Planning and Budgeting and representatives of the local governments, service providers, development partners and private sector. Also, key structures such as the Midwifery Council and Community Health Registration Practitioners Board of Nigeria were represented. Consultants were engaged to facilitate the session.

To better inform planning, projections for each year of the framework’s implementation were developed with the aid of a health economist from FHI 360. The calculations and assumptions made for these projections are described in Appendix 1. Where feasible, Gombe state-specific data, particularly for CPR and method use, were used to inform the projections. Other data sources were the Nigerian DHS data 2008, National Census 2006 and reports on live births, deaths and stillbirths registration in Nigeria (1994– 2007). Databases of the United Nations Development Program and International Organization on Migration as well as journal publications were also sources of other relevant demographic data. (Please see

13 a separate publication for more details: Policy Analysis of Benefits and Program Requirements of Family Planning in Gombe State.)10 The projection exercise, using data from NDHS 2008,1 generated scenarios and targets up to 2015, which is the duration of this plan. This exercise was informed by the overall goal, as determined from the extensive planning exercise above. The data from the projection exercise is reflected in expected outcomes and targets for this framework.

During an implementation planning meeting in July 2012, the stakeholders decided to focus the framework on providing the three FP methods that can be provided at the primary health centre (PHC) level (condoms, pills and injectables) and the five FP methods that can be provided at the secondary facility level (PHC level methods plus IUDs and implants). For that reason, surgical methods (such as vasectomy and tubal ligation) were not included in this framework, as they can be provided only at the tertiary level and only two tertiary facilities exist in Gombe state. The traditional methods, standard days method and lactational amenorrhea method, were not identified as formal methods for provision by the FMoH at the time and hence were not included in the framework.

In addition, the implementation timeline for the framework was discussed. Participants determined that it should be a three-year plan, 2013 to 2015, to align with Gombe’s State Strategic Health Development Plan (SSHDP) 2010 2015,5 which aims to increase the modern contraceptive prevalence rate from 4.5 percent in 2008 to 12 percent by 2015. ‒ Review Meeting Following the planning meeting held in July 2012, a review meeting was conducted in October 2012 with broader stakeholder participation to review the draft framework. Stakeholders at this meeting included the Gombe state RH TWG, implementing partners in Gombe state and the Community Practitioners’ Registration Board of Nigeria.

Finalization of the Framework The framework’s implementation timeline was initially aligned with the Gombe State Strategic Health Development Plan, which ends in 2015. However, in light of the Federal Government’s commitment at the London Summit on Family Planning in July 2012 to achieve a CPR of 36 percent by 2018, the plan was amended to cover a period of six years and end in 2018 (DFID, 2012).11

In addition, this new implementation timeline for the framework now aligns with the FP goals outlined in the National Policy on Population for Sustainable Development (NPPSD) 2004.12 This policy recognizes the adverse effect of rapid population growth on development and commits to increasing the national CPR by 2 percent each year through 2018 to reduce the current level of unmet need.

14 GOALS, OBJECTIVES AND STRATEGIC INTERVENTION AREAS The implementation of this framework will result in improved FP service delivery by increasing coverage, training and 3 support for FP across the state, and ultimately will improve the contraceptive prevalence rate. This framework is guided by its goal, four objectives and the activities categorized under eight strategic intervention areas, which are graphically depicted in Figure 4.

Figure 4: Goals, objectives and strategic areas of intervention

3.1 Goal The goal of this framework is to improve access to and uptake of FP methods in Gombe State to increase the contraceptive prevalence rate to 22.1 percent in 2018. This goal is based on an assumed CPR of 8.8 percent in 2012, which was projected based on the Nigeria DHS 2008 CPR of 4.5 percent.2 This goal may require updating if data demonstrating a change in CPR for Gombe state is made available during the implementation period for this framework.

15 3.2 Objectives and Targets

This framework includes four specific objectives and nine related targets that are described below. Annual progression towards these targets between the years 2013 and 2018 is depicted in Table 2. Further details about how each target was calculated and justification for its use as an indicator are provided in Appendix 1.

Objective 1: Build the capacity of all CHEWs, doctors, nurses and midwives working in RH and FP to provide cadre-appropriate FP services in Gombe state by 2018.

• Target 1: Train 100 percent of CHEWs to provide FP services in facilities and at the community-level in Gombe state by 2018.

• Target 2: Train 100 percent of all doctors in gynaecology and nurses and midwives in Maternity Services to provide FP services in Gombe state by 2018.

Objective 2: Expand the availability of FP commodities offered by cadre- appropriate providers in the wards, primary health centres, secondary and tertiary facilities in Gombe state by 2018.

• Target 1: Ensure the availability of a method mix of at least three FP methods (pills, condoms and injectables) in 100 percent of the wards in Gombe state by 2018

• Target 2: Ensure the availability of a method mix of at least three FP methods (pills, condoms and injectables) in 100 percent of primary health centres in Gombe state by 2018.

• Target 3: Ensure the availability of a method mix of at least five FP methods (pills, condoms, injectables, implants and IUDs) in 100 percent of public secondary and tertiary facilities in Gombe state by 2018.

Objective 3: Increase the use of FP methods among men, women and young persons of reproductive age in Gombe state by 2018.

• Target 1: Increase use of FP by 20 percent among women of reproductive age in Gombe state by 2018.

• Target 2: Increase support for FP by 50 percent among men, women and young persons of reproductive health in Gombe state by 2018.

Objective 4: Increase the level of state and community support for FP services in Gombe state by 2018.

• Target 1: At least 70 percent of community leaders permit the implementation of community- based FP in their communities in Gombe state by 2018.

• Target 2: 100 percent of policymakers at the state- and LGA-level support implementation of FP programmes in Gombe state by 2018.

Table 1: Annual Progression towards Targets by Objective

OBJECTIVE 1 OBJECTIVE 2 OBJECTIVE 3 OBJECTIVE 4 GOAL TARGET 1 TARGET 2 TARGET 1 TARGET 2 TARGET 3 TARGET 1 TARGET 2 TARGET 1 TARGET 2 Secondary & % increase CHEWs1 Communities PHCs tertiary in men, Policy- Clinicians % Community CPR trained in three (i.e. wards) providing facilities women & maker Year trained in five FP Users Increase leader (%) FP methods providing three three FP providing youth’s support4 FP methods2 in FP use support3 (%) (add55/year) FP methods methods five FP support (%) methods 2012 baseline 8.82 5% (83) 20% (41) 9% (10) 20% (101) 12.5% (2) 38,562 N/A 0 10 10 2013 9.90 30% (512) 30% (61) 30% (35) 30% (152) 30% (5) 44,483 15.4 5 25 25 2014 11.62 60% (1,058) 60% (121) 60% (69) 60% (303) 60% (10) 53,658 20.6 10 30 40 2015 13.64 100% (1,817) 100% (201) 100% (114) 100% (505) 100% (16) 64,730 20.6 20 40 55 2016 16.02 100% (1,872) 100% (201) 100% (114 100% (505) 100% (16) 78,131 20.7 30 50 70 2017 18.81 100% (1,927) 100% (201) 100% (114) 100% (505) 100% (16) 94,279 20.7 40 60 85

2018 22.10 100% (1,982) 100% (201) 100% (114) 100% (505) 100% (16) 113,837 20.7 50 70 100

1 Includes Junior CHEWs. Justification for the targets is provided in Appendix 1. 2 Clinicians include nurse/midwives and doctors. Justification for the targets is provided in Appendix 1. 3 Community leaders are district heads and religious leaders. Justification for the targets is provided in Appendix 1. 4 Policymakers are emirs, commissioners and permanent secretaries. Justification for the targets is provided in Appendix 1.

3.3 Eight Strategic Intervention Areas

Eight strategic intervention areas were identified by the National CBA TWG as key components of implementation that must be addressed to ensure successful community-based FP services and can also be applied to expanded FP services at the facility-level.7 Therefore, all of the activities implemented under this framework address a strategic intervention area.

1. Advocacy and social mobilization for an enabling environment to support FP

The State Ministries of Health (SMoH), other ministries, LGAs, and traditional and religious leaders must be engaged continuously to mobilize political will to sustain buy-in for expanded provision of FP services, and especially the community-based provision of injectables by CHEWs, as this is a new task-sharing practice. Further, partnerships with civil society organizations (CSOs) and community-based organizations (CBOs) are strategic for community mobilization and demand creation. These entities have a role to play in increasing men’s and women’s awareness of FP, dispelling myths and misconceptions, as well as encouraging acceptance of and desire for FP. Community members must be engaged to gain an understanding of their concerns and information needs. The messages can be presented in a report, slide presentation, poster, video or other format.

2. Training and capacity building

Proper training is critical to ensuring the delivery of quality FP services. A training needs assessment will be conducted to understand learning needs that exist in FP service delivery in Gombe state. For example, a known need is training on community-based provision of injectables for CHEWs. With this information, a training plan will be developed for all health cadres. SMoH staff and representatives from the Community Health Practitioners Registration Board will be identified and trained as trainers using nationally validated curricula and job aids. This pool of master trainers in the state will be supported to step down the training to other health workers. Additionally, the SMoH will train health workers in logistics management systems to build their capacity in quantification and forecasting as part of the strategy to minimize FP commodities stock-out. In addition, to boost the pre-service training of CHEWs, the plan also includes activities to ensure the Gombe State School of Health Technology is reaccredited.

3. Service provision and supportive supervision

Once trained, health worker cadres will be provided with the necessary supplies to begin providing FP services and to expand access with guidance from their supervisors. Supervisors for each health worker cadre will need to conduct regular supportive meetings and report data to LGA and state health committees on the findings from these meetings. Safety, supportive supervision, monitoring and evaluation will be highlighted as critical factors in operationalizing the service delivery component.

4. Quality assurance

This will be a key strategy to ensure the delivery of high quality FP services. Appropriate quality assurance approaches will be introduced in areas of training and capacity building, as well as FP commodities security. These approaches would include the supportive supervision mentioned above, using a standard checklist on a regular basis; review of the referral and linkages system to minimize missed opportunity; on-site on-the-job refresher trainings and mentoring; and provision of standard operating procedures (SOPs), job aids and guidelines to standardize service quality.

18 5. Commodities and logistics management

Commodity stock-outs present a major challenge to facility-based services and CBD programmes. Therefore, this framework for expanded service delivery will be linked to the state’s new plan for commodities and logistics management that will ensure a steady supply of commodities and other supplies such as auto-disable syringes. The commodities management plan will adopt the review and resupply meetings model already in use by UNFPA and several projects to ensure regular supply of FP commodities to facilities. The plan will also include contingency plans in the event of a stock-out. A sound logistics system will ensure that contraceptive commodities and other supplies are distributed smoothly, in good condition and on time.

6. Finance and resource mobilization, including private sector involvement

The additional financial, institutional and human resources needed to support expanded access to FP services will require Gombe state officials to seek out new partnerships with government, multilaterals, NGOs and the private sector and private donors. Linkages and partnerships among existing government programmes and implementing organizations’ projects will be established to leverage funding. The Gombe SMoH will lead coordination of the expanded services effort to ensure these services are integral to their state financial, strategic and monitoring plans. Once donors and other resource providers have been engaged, a committed resource team can be formed to work on planning and allocating financial and human resources appropriately to support scale-up and sustained implementation.

7. Monitoring and reporting system

A Monitoring and Reporting Team composed of state and LGA staff already tasked with monitoring and evaluation (M&E) activities and staff from implementing partners who may be supporting expanded FP service delivery will assess the progress, lessons learned, outcomes and impact of the FP programme as it expands to serve new audiences. Key indicators will be determined for new services and routinely measured. Tracking forms and other M&E procedures will be reviewed to determine if updates are needed so the resulting data can be used to continually adapt and improve implementation. The Monitoring and Reporting Team will formulate effective mechanisms for ensuring that information is fed back to key stakeholders and used to continually adapt and improve implementation.

8. Integration of FP with HIV/AIDS and MNCH to address missed opportunities to curb the HIV epidemic

Integrated services are beneficial because clients can access more than one service during a single visit. Integrated services have the potential to be more efficient and effective. Integration enhances not only sharing of existing infrastructure or facilities and personnel, and it also maximizes the management of service delivery and simplifies logistics. Trainings to health workers will emphasize the importance of integrating the various services they provide and build their capacity to provide integrated services

3.4 Benefits and Impact of Expanded Family Planning Service Delivery

In addition to the overarching goal of achieving a CPR of 22.1 percent by 2018, broader health indicators can be measured to assess the impact of this framework’s family planning achievements on Gombe state’s population in 2018. This framework does not aim to measure these impact indicators but assumes that future demographic and health surveys will capture this information which can be used to monitor the framework’s far-reaching impact.

Table 2: Family Planning Impact Indicators

DISABILITY- INFANT UNDER-5 MATERNAL ADJUSTED LIFE PREGNANCIES BIRTHS MORTALITIES MORTALITIES MORTALITIES ABORTIONS YEARS (DALYS) YEAR CPR (%) CYP AVERTED AVERTED AVERTED AVERTED AVERTED AVERTED AVERTED 2012 8.82 41,470 23,697 17,232 1,675 3,253 190 4,329 10,227 baseline 9.90 48,269 27,582 20,057 1,950 3,787 221 5,039 11,904 2013 11.62 59,022 33,727 24,526 2,384 4,630 270 6,161 14,556 2014 13.64 72,016 41,152 29,925 2,909 5,650 329 7,517 17,760 2015 16.02 86,855 49,632 36,092 3,508 6,814 397 9,066 21,420 2016 18.81 105,243 60,139 43,732 4,251 8,257 481 10,986 25,955 2017 22.10 127,612 72,921 53,028 5,154 10,012 583 13,321 31,471 2018 N/A 540,486 308,849 224,593 21,830 42,403 2,471 56,419 133,292 Total

20 PLAN OF ACTION This section of the framework was developed during consultations with the SMoH officials and the Gombe RH TWG to outline the activities that must be implemented to achieve each of the four objectives and related targets to ultimately lead to an increased CPR of 22.1 percent. The activities have been grouped 4 into strategic intervention areas as described in Section 3.3. The stakeholders responsible, timeframe for implementation and resources required for each activity are also presented.

4.1 Objective 1

Objective 1: Build the capacity of all CHEWs, doctors, nurses and midwives working in RH and FP to provide cadre-appropriate FP services in Gombe state by 2018.

• Target 1: Train 100 percent of CHEWs to provide FP services in facilities and at the community-level in Gombe state by 2018.

• Target 2: Train 100 percent of all doctors in gynaecology and nurses and midwives in Maternity Services to provide FP services in Gombe state by 2018.

COSTING OF THE STRATEGIC ACTIVITY IDENTIFIED TIME FRAME REQUIRED INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013 2018 RESOURCES (NGN)

1. Advocacy 1.1.1 Advocate for reaccreditation (1) Develop advocacy kit. CHPRBN, FMoH, State 2013 (Q4)‒ 180,000 and social of the Gombe State School (2) Conduct advocacy visits. Executive, School of Health mobilization for Health Technology. Technology for an enabling environment 1.1.2 Conduct advocacy visits to 2014 (Q1) 360,000 all LGAs to inform them of capacity development plans.

21 COSTING OF THE STRATEGIC ACTIVITY IDENTIFIED TIME FRAME REQUIRED INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013 2018 RESOURCES (NGN)

5 1.1.3 Liaise with the SMoH and MCH, FP, ARH coordinators 2014 (Q1)‒ 0 HMB to designate/brand the and DPHC two tertiary and 11 secondary health facilities in Gombe state as referral sites. 2. Training 1.2.1 Identify all eligible health 2013(Q4) 0 and capacity care workers and assess building training needs. 1.2.2 Develop training plan. (1) Review training needs 2013(Q4) 135,000 assessment. (2) Quantify number and cadre of personal to be trained. (3) Document roll-out of training. (4) Budget training cost. 1.2.3 Secure required approvals (1) Review training plan (see RH TWG, SMoH, SMoE, 2014(Q1) 0 for training. below). (2) Provide resources SMO, SMoLGA for training. (3) Provide permissions for public providers.

5 Costs of 0 naira indicate the expenses for these activities have been captured by related activities.

22 COSTING OF THE STRATEGIC ACTIVITY IDENTIFIED TIME FRAME REQUIRED INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013 2018 RESOURCES (NGN)

1.2.4 Conduct update trainings for (1) Train the master trainers. RH TWG, LGAs, DPHC, 2014 (Q1)‒ 7,776,000 master trainers including (2) Review and adopt the development partners supportive supervision and national training manual for HIV counseling and testing. each cadre. (3) Identify training participants. (4) Prepare logistics for training. (5) Conduct training in phases for the cadres. (6) Incorporate CBA, infection control, CLMS and injection safety into FP training agenda. 1.2.5 Conduct cadre-appropriate (1) Review and adopt the RH TWG, SMoH, LGA and 2014 (Q2) - 47,550,000 step-down trainings for national training manual for development partners. 2018 (Q3) health workers on each cadre. (2) Identify advocacy/sensitization, training participants. (3) effective communication, Prepare logistics for training. CLMS, injection safety, HIV (4) Conduct training in phases counseling and testing, for the cadres. (5) Incorporate waste management, overall infection control CLMS and knowledge and practical injection safety into FP training application of modern FP agenda. methods. 3. Service 1.3.1 Adapt/develop culturally Job aids (SOPs, clinical 2013 (Q4) - 2,320,000 provision and appropriate job aids and IEC protocols, MEC wheels, MEC 2014 (Q1) supportive materials to guide service wall chart, GATHER charts, supervision provision at all service CBD algorithm for delivery levels. management of side effects) and IEC materials (such as posters) 1.3.2 Print job aids and IEC 2014 (Q1) 60,000,000 materials. 1.3.3 Distribute job aids. 2014 (Q2) - 0

23 COSTING OF THE STRATEGIC ACTIVITY IDENTIFIED TIME FRAME REQUIRED INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013 2018 RESOURCES (NGN)

2018 (Q3)‒

1.3.4 Integrate on-the-job (1) Compile the list of public PHC coordinators, M&E 2014 (Q2) - 0 training and supervision of health personnel trained. (2) officer, state FP 2018 (Q3) FP services into routine ISS, Develop a checklist. coordinators, CLMS officer, including CBA supervision NHMIS desk officer

1.3.5 Conduct quarterly DPHC, SMoH, LGAs and RH 2014–2018 0 supportive supervision using TWG, NURHI & FHI 360 (Quarterly) performance standard, CLMS supervisory checklist and other tools at all service delivery levels.

1.3.6 Conduct bi-monthly review (1) Identify training SMoH and FMoH 2014 - 0 meeting with MSS staff, participants. (2) Prepare 2018(Bi- CHOs, HF in-charges and logistics for training. (3) Monthly) LGA MCH coordinators. Conduct training topics on CLMS tools for the MSS staff. 1.3.7 Conduct quarterly review (1) Identify meeting FP, ARH, MCH Coordinators 2014 (Q2 0 meeting with LGA MCH participants. (2) Prepare 2018 (Q3) coordinators and State meeting logistics. (3) Conduct ‒ MCH, ARH and FP the meeting. coordinators. 1.3.8 Institute waste Train providers on waste Quality improvement 2014 (Q2) - 0 management and infection management and injection consultants 2018 (Q3) prevention practices in safety and universal health facilities of Gombe state.

24 COSTING OF THE STRATEGIC ACTIVITY IDENTIFIED TIME FRAME REQUIRED INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013 2018 RESOURCES (NGN)

4. Quality 1.4.1 Assure quality of FP (1) Maintain adequate FP 2014 (Q2)‒ - 0 assurance training. trainer and trainee ration. (2) 2018 (Q3) Implement competency based trainings. (3) Conduct pre- and post-tests before and after each training.

1.4.2 Conduct post-training (1) Cross-check challenges SMoH, LGAs and RH TWG 2014 (Q3) - 0 follow-up supportive with maintaining FP stock at 2018 (Q3) supervisory visits. facilities and community level. (2) Observe health workers providing FP services. (3) Document cases of adverse reactions or issues with injection safety.

1.4.3 Conduct post-training SMoH, LGAs and RH TWG 2014 (Q2) - 0 follow-up reviews with 2018 (Q3) performance reviews in each LGA. 1.4.4 Adapt performance Consultants, SMoH, LGAs 2013 (Q4) – 0 standards for FP service and RH TWG 2014(Q1) provision. 1.4.5 Print copies of performance SMoH, Implementing 2014 (Q1) 1,000,000 standards for PHCs, Partners secondary and tertiary health facilities. 1.4.6 Conduct baseline study of Consultants, SMoH, LGAs 2013 (Q4) 16,500,000 primary and secondary and RH TWG health facilities in Gombe state to determine quality gaps.

25 COSTING OF THE STRATEGIC ACTIVITY IDENTIFIED TIME FRAME REQUIRED INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013 2018 RESOURCES (NGN)

1.4.7 Disseminate results and SMoH, quality improvement 2014 (Q1)‒ 900,000 develop action plan towards consultants/resource improving service quality persons, LGAs and RH TWG based on performance gaps. and HF staff

1.4.8 Form quality improvement Trainers and HF in-charges 2014 (Q2) - 0 teams to monitor 2018 (Q3) implementation of quality improvement efforts. 1.4.9 Provide quarterly supportive State, LGA MCH coordinator 2014 (Q2) - 0 supervision to monitor and RH TWG 2018 (Q3) quality improvement effects using performance standards at all service delivery levels. 1.4.10 Conduct midline evaluation Quality improvement 2016 (Q1) 1,500,000 in all health facilities consultant participating in the quality improvement effort. 1.4.11 Continue to implement and HF staff, LGA FP 2014 (Q2) - 0 monitor quality coordinator, QITs and RH 2018 (Q3) improvement efforts in TWG health facilities of Gombe state. 1.4.12 Conduct end-line evaluation Consultants, SMoH, LGAs 2018 (Q3) 1,500,000 of quality improvement and RH TWG efforts. 1.4.13 Conduct recognition events Consultants, SMoH, LGAs 2014 (Q2) - 300,000 and brand health facilities and RH TWG 2018 (Q3) (HFs) as quality sites.

26 COSTING OF THE STRATEGIC ACTIVITY IDENTIFIED TIME FRAME REQUIRED INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013 2018 RESOURCES (NGN)

1.4.14 Procure waste management DPHC, SMoH, LGAs and RH 2014 (Q2)‒ - 28,150,000 equipment, infection TWG 2018 (Q3) prevention equipment and injection safety equipment (and consumables). 5. 1.5.1 Procure CBA kits and MCH, FP, ARH and state 2014 (Q1) - 4,000,000 Commodities injection safety boxes for trainers 2018 (Q3) and logistics eligible providers. management 1.5.2 Distribute kits and injection MCH, FP, ARH and DPHC 2014 (Q2) - 0 safety boxes to CBA 2018 (Q3) providers.

1.5.3 Procure and distribute HIV MCH, FP, ARH, SASCP and 2014 (Q1) - 0 test kits to all FP clinics. DPHC 2018 (Q3)

1.5.4 Conduct quarterly Conduct periodic follow-up LGA, DPHC 2014 (Q2) - 0 supportive supervision at visits. 2018 (Q3) health facilities to determine adequacy of equipment and infrastructure by LGA supervisors. 1.5.5 Conduct quarterly (1) Develop a follow-up SMoH 2014 (Q1) - 0 supportive supervision of schedule. (2) Prepare logistics 2018 (Q3) LGAs to determine for the meeting. (3) Conduct adequacy of equipment and meeting with the LGA infrastructure by state. supervisors. 1.5.6 Conduct site assessments at SMoH, LGA 2014 (Q1) - 0 all health facilities to 2018 (Q1) determine renovation, (Annually) commodity and equipment needs.

27 COSTING OF THE STRATEGIC ACTIVITY IDENTIFIED TIME FRAME REQUIRED INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013 2018 RESOURCES (NGN)

1.5.7 Procure basic and Procure basic equipment: SMoH and LGAs 2014 (Q1)‒ - 84,450,000 specialized equipment for weighing scale, 2018 (Q3) provision of FP services. sphygmomanometer, stethoscope, injection safety boxes, IUCD kit, MVA kit, insertion couch, angle poise lamp, autoclave, screen, instrument trolley, trays, gallipots, chaetae forceps containers and chaetae forceps, mosquito artery forceps, BP apparatus.

1.5.8 Distribute equipment to SMoH and LGAs 2014 (Q2) - 563,000 appropriate facility (by level 2018 (Q3) of service provision). 1.5.9 Procure waste management 2014 (Q1) - 56,300,000 equipment (dustbin, utility 2018 (Q3) gloves, boots, mask, goggles and aprons). 1.5.10 Conduct renovation of 2014 (Q1) - 140,750,000 approved FP clinics. 2018 (Q3)

1.5.11 Conduct post-renovation 2014 (Q2) - 563,000 inspection. 2018 (Q3) 6. Finance 1.6.1 Allocate financial resources (1) Enlist the HR materials 2014 (Q1) 0 and resources for human resource needs needed. (2) Create a detailed and capacity building. budget on the HR materials needed.

28 COSTING OF THE STRATEGIC ACTIVITY IDENTIFIED TIME FRAME REQUIRED INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013 2018 RESOURCES (NGN)

1.6.2 Engage development (1) Enlist the development 2014 (Q1)‒ 0 partners, NGOs, CSOs and partners, NGOs and private private sector players organizations to be visited. (2) towards supporting the Develop proposals and budget provision of FP services to for the resources. underserved communities and at-risk population. 1.6.3 Enlist additional CHEWs and (1) Enlist the additional 2014 (Q1) 0 JCHEWs; train and build the CHEWs and JCHEWs. (2) capacity of existing and Identify the participants of the enlisted CHEWs and training. (3) Prepare logistics JCHEWs. for the training. (4) Conduct training. (5) Conduct periodical follow-up visits. 7. Monitoring 1.7.1 Reprint and distribute copies (1) Review and compile the SMoH, LGA, DPHC 2014 (Q1) - 2,815,000 and reporting of daily activity registers, daily activity registers, daily 2018 (Q2) daily consumption records consumption record forms, forms, monthly summary and monthly summary and and requisition forms. requisition forms. (2) Reprint and distribute the documents. 1.7.2 Distribute copies of FP and SMoH, LGA, SASCP, DPHC 2014 (Q2) - 0 HCT data collection tools to 2018 (Q3) facilities as required.

1.7.3 Develop indicators to track (1) Enlist the development SMoH, LGAs and 2013 (Q4) – 0 FP service provision and partners, NGOs and private development partners 2014 (Q1) utilization across the state. organizations to participate. (2) Conduct meeting. 1.7.4 Develop M&E reporting (1) Enlist the development SMoH, LGAs, and 2013 (Q4) – 0 plan. partners, NGOs and private development partners 2014 (Q1) organizations to participate. (2) Conduct meeting.

29 COSTING OF THE STRATEGIC ACTIVITY IDENTIFIED TIME FRAME REQUIRED INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013 2018 RESOURCES (NGN)

1.7.5 Conduct quarterly data SMoH, LGA 2014 (Q2)‒ - 0 analysis and reporting 2018 (Q3) (linked to quarterly review and resupply meetings). 1.7.6 Develop and disseminate 2014-2018 600,000 annual CLMS report for Gombe state.

8. Integration 1.8.1 Conduct integrated PAC FP MCH, FP, ARH and state 2014 (Q2) - 0 of FP with and Post-Partum FP) trainers 2018 (Q3) HIV/AIDS trainings into MCH services and MNCH of secondary and tertiary health facilities in Gombe state (link with HW trainings). Subtotal 458,212,000 Objective 1

30 4.2 Objective 2

Objective 2: Expand the availability of FP commodities offered by cadre-appropriate providers in the wards, primary health centres, and secondary and tertiary facilities in Gombe state by 2018.

• Target 1: Ensure the availability of a mix of at least three FP methods (pills, condoms and injectables) in 100 percent of the wards in Gombe state by 2018.

• Target 2: Ensure the availability of a mix of at least three FP methods (pills, condoms and injectables) in 100 percent of primary health centres in Gombe state by 2018.

COSTING OF STRATEGIC THE REQUIRED INTERVENTION ACTIVITY IDENTIFIED TIME FRAME RESOURCES AREA CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013–2018 (NGN) 1. Advocacy 2.1.1 Advocate for budgetary allocation Review quantification (see State executive and 2013-2018 225,000 and social for FP services at all levels in the section on commodity and legislative bodies, MoF, mobilization state. logistics below) and allocate MoEP, SMoH, 11 local for an budgetary allocation. governments councils, donors, civil society enabling organizations and faith- environment based organizations 2.1.2 Conduct a one-day stakeholder (1) Identify stakeholder Chairmen of the MoH, 2013 (Q4) 1,360,000 meeting to mobilize political will categories. (2) Convene Ministry of Women Affairs, and leadership for provision of stakeholder meeting. (3) Ministry for LG and quality FP services. Disseminate new FP/RH Chieftaincy Affairs, LGSC, policy guidelines to relevant MoE, MoEP, MoF and LGA; stakeholders. House Committee on Health/Appropriation; religious leaders; and coordinators of the Gombe

31 COSTING OF STRATEGIC THE REQUIRED INTERVENTION ACTIVITY IDENTIFIED TIME FRAME RESOURCES AREA CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013–2018 (NGN) SACA , CHPRBN, APHPN, MDCN, NMCN, NMA, AGMPN and PHC

2.1.3 Convene a one-day state RH Conduct quarterly meetings. RH TWG members and 2013 (Q4) - 0 TWG. (Link to quarterly review other stakeholders 2018 (Q3) meeting)

2.Training and 2.2.2 Conduct a two-day training on MCH, RH and FP 2014 (Q1) 648,000 capacity supportive supervision for CLMS coordinator building for RH TWG members).

2.2.3 Conduct training on CLMS for (1) Identify training SMoH, LGA 2014 (Q2) - 0 HWs (CHEWs, nurses, doctors). participants. (2) Review 2018 (Q3) (Link to HW training) existing CLMS training curriculum. (3) Prepare logistics for training. (4) Conduct CLMS training. 3. Service 2.3.1 Conduct supportive supervisory (1) Select facility to be visited. MCH coordinators 2014 (Q2) - 4,752,000 provision and visit (ISS) to ensure availability of (2) Conduct the visit. 2018 (Q3) supportive FP commodities and appropriate supervision method mix at LGA level.

32 COSTING OF STRATEGIC THE REQUIRED INTERVENTION ACTIVITY IDENTIFIED TIME FRAME RESOURCES AREA CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013–2018 (NGN) 2.3.2 Conduct one-day ISS training to (1) Select LGA and facilities to RH, MCH, FP, ARH 2014 (Q1) 1,584,000 ensure availability of FP be visited. (2) Conduct the coordinators commodities and appropriate visit. method mix at state level.

2.3.3 Conduct monthly review meeting (1) Identify meeting FP providers, MCH 2014 (Q2) - 11,880,000 with health facility staff and LGA participants. (2) Prepare coordinators 2018 (Q3) MCH coordinators at the LGA meeting logistics. (3) Conduct level. the meeting. 2.3.4 Conduct quarterly review and (1) Identify meeting FP, ARH, MCH coordinators 2014 (Q2) - 3,600,000 resupply meetings with LGA MCH participants. (2) Prepare 2018 (Q3) coordinators and state MCH and meeting logistics. (3) Conduct FP coordinators at the state level the meeting (link with RH TWG meetings).

2.3.5 Establish linkages and referral (1) Use GIS to map service MCH, FP, ARH and state 2014 (Q2) - 0 mechanisms among community- providers and service delivery trainers 2018 (Q3) based providers, PHCs, secondary points. (2) Draft service and tertiary health facilities to delivery directory. ensure availability of method mix.

4. Quality 2.4.1 Adapt SOPs and international Extended RH TWG 2014 (Q1) 1,620,000 assurance standards for FP commodity management/CLMS.

2.4.2 Print SOPs for CLMS. SMoH 2014 (Q1) - 3,000,000 2018 (Q2) 2.4.3 Distribute SOPs to all state and SMoH, LGA 2014 (Q2) - 0 LGA stores. 2018 (Q3)

33 COSTING OF STRATEGIC THE REQUIRED INTERVENTION ACTIVITY IDENTIFIED TIME FRAME RESOURCES AREA CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013–2018 (NGN) 2.4.4 Conduct routine inspection of FP FP coordinator 2013 (Q4) - 0 commodities being supplied to 2018 (Q3) the state.

5. 2.5.1 Convene meeting to develop FP (1) Identify the stakeholders RH TWG, SMoH, LGA and 2014 (Q1) 1,620,000 Commodities commodity management and involved. (2) Prepare meeting development partners. and logistics procurement strategies to inform logistics. (3) Conduct management the state plan for commodities stakeholders meeting. and logistics management.

2.5.2 Quantify commodity requirements (1) Review facility requisition SMoH 2014 (Q1) - 580,000 and develop specific procurement and use. (2) Integrate targets 2018 (Q2) plans (biannually). from framework on commodity quantities required.

2.5.3 Procure FP commodities. SMoH 2014 (Q1) - 500,550,000 2018 (Q3)

2.5.4 Procure FP consumables. SMoH, HMB 2014 (Q1) - 0 2018 (Q3)

2.5.5 Train health care workers on the (1) Identify training SMoH, LGA 2014 (Q2) - 0 LMIS tools (link with HW participants. (2) Prepare 2018 (Q3) training). logistics for training. (3) Conduct training on LMIS tools for selected health workers. 2.5.6 Conduct monthly review and (1) Send out invitations. (2) LGA, service providers 2014 (Q2) - 0 resupply meeting with health Prepare meeting logistics. (3) 2018 (Q3) facility staff and LGA MCH Conduct stakeholders meeting. coordinators at the LGA level (link with supportive supervision).

34 COSTING OF STRATEGIC THE REQUIRED INTERVENTION ACTIVITY IDENTIFIED TIME FRAME RESOURCES AREA CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013–2018 (NGN) 2.5.7 Conduct quarterly review and (1) Send out invitations. (2) SMoH, LGA 2014 (Q2) - 0 resupply meetings with LGA MCH Prepare meeting logistics. (3) 2018 (Q3) coordinators and state MCH and Conduct stakeholders meeting. FP coordinators at the state level (link with supportive supervision. 6. Finance and 2.6.1 Conduct a stakeholder meeting to (1) Identify the stakeholders RH TWG, SMoH, LGA and 2014 (Q1) 0 resources agree on the scope of involved. (2) Prepare meeting development partners intervention, projected costs and logistics. (3) Conduct commitments from stakeholders. stakeholders meeting. 2.6.2 Engage government, (1) Compile the development RH TWG 2013 (Q4) – 0 development partners, NGOs and partners, NGOs and private 2014 (Q1) the private sector to commit organizations to be visited. (2) resources and take ownership of Develop proposals and budget the program. for the resources. 2.6.3 Constitute a program (1) Identify the members of SMoH, RH TWG, LGA, 2014 (Q1) 0 management team that will track the project management development partners. and coordinate resource team. (2) Track and mobilization and utilization (link coordinate resource with FP logistics procurement mobilization and use. planning meeting) 2.6.4 Establish linkages and (1) Conduct FGDs with the SMoH, RH TWG, LGA, 2013 Q4 - 0 partnerships between CHPRBN, representatives of the development partners. 2014 (Q1) Schools of Technology, FMoH and stakeholders. (2) Explore the implementing organizations to areas in which the leverage existing funding. stakeholders can be linked. 7. Monitoring 2.7.1 Constitute a monitoring and (1) Hold an inaugural meeting PHC coordinators, M&E 2014 (Q1) - 2,397,600 and reporting reporting team at both the LGA to constitute the M&E team. officer, MCH , community 2018 (Q3) and state levels. (2) Implement monthly representatives meetings in the first year then quarterly meetings subsequently.

35 COSTING OF STRATEGIC THE REQUIRED INTERVENTION ACTIVITY IDENTIFIED TIME FRAME RESOURCES AREA CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013–2018 (NGN) 2.7.2 Develop indicators that will (1) Develop an inventory PHC coordinators, M&E 2014 (Q1) 0 monitor availability of the method checklist to monitor the officer, MCH, state FP mix within the community (link availability of the commodity coordinators, CLMS officer with M&E inaugural meeting). in stock. (2) Support supervision to ensure above stated checklist. 2.7.3 Integrate community-level FP (1) Review state health PHC coordinators, M&E 2014 (Q1) 0 data elements (particularly for information forms to capture officer, MCH, state FP injectables) into state level services rendered at the coordinators, CLMS officer, NHMIS (link with M&E inaugural community level. Provide NHMIS desk officer meeting). NHMIS reporting forms in all centres. (2) Ensure prompt and proper recording and submission of all the FP services rendered. 2.7.4 Update and adopt CBA activity Implement a meeting to PHC coordinators, M&E 2014 (Q1) 0 sheets, community services review the CBA activity sheets officer, MCH, state FP register and report form to and capture the injectable coordinators, CLMS officer include injectables. services. 2.7.5 Reprint copies of daily activity SMoH, LGA 2014 (Q1) - 0 registers, daily consumption 2018 (Q2) record forms, monthly summary and requisition forms (link with M&E in objective 2).

2.7.6 Distribute M&E tools. SMoH, LGA 2014 (Q2) - 0 2018 (Q3) 2.7.7 Conduct monthly review meetings 2014 (Q2) - 0 with health facility staff and LGA 2018 (Q3) MCH coordinators at the LGA level (link with supportive

36 COSTING OF STRATEGIC THE REQUIRED INTERVENTION ACTIVITY IDENTIFIED TIME FRAME RESOURCES AREA CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013–2018 (NGN) supervision).

2.7.8 Conduct quarterly review and SMoH, LGA 2014 (Q2) - 0 resupply meetings with LGA MCH 2018 (Q3) coordinators and state MCH and FP coordinators at the state level (link with supportive supervision,). 8. Integration 2.8.1 Develop a framework to integrate (1) Conduct a review meeting. 2014 (Q1) 0 of FP with these services. (2) Identify meeting HIV/AIDS and participants. (3) Prepare MNCH meeting logistics. (4) Inculcate the agreement reached at the meeting into the framework. 2.8.2 Supply HIV test kits to FP clinics. 2014 (Q2) - 0 2018 (Q3)

2.8.3 Support FP service provision (1) Conduct orientation 2014 (Q2) - 1,200,000 during biannual MNCH weeks and meetings for staff involved in 2018 (Q3) NIDs. special events. (2) Mobilize resources for service provision: commodities and consumables. (3) Provide services. Subtotal 535,016,600 Objective 2

37 4.3 Objective 3

Objective 3: Increase the use of FP methods among men, women and young persons of reproductive age in Gombe state by 2018.

• Target 1: Increase use of FP by 20 percent among women of reproductive age by in Gombe state by 2018.

• Target 2: Increase support for FP by 50 percent among men, women and young persons of reproductive health in Gombe state by 2018.

COSTING OF TIME THE REQUIRED STRATEGIC ACTIVITY IDENTIFIED FRAME RESOURCES INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013‒2018 (NGN) 1. Advocacy 3.1.1 Develop key FP (child spacing) Develop messages and SMoH, SMWASD, SSMO, 2014 (Q1) and social messages for priority audience programs for media and print CSO, ARH coordinators, mobilization during advocacy, communication for priority audience. MAP resource persons, CBO, 2,900,000 for an and social mobilization activities. community reps enabling environment 3.1.2 Advocate to the SMoE to train Liaise with MoE to ensure MoH, ,MOE, MOYD,CSOs, 2013 (Q4) – young people on FP/RH availability of family life development partners, ARH 2018 (Q3) component of FLHE using the education (FLE) curriculum in coordinator, state master 0 approved national curricula. all senior secondary schools. trainers, resource persons

3.1.3 Conduct community-based Conduct community-based LGA SMO, CBOs, CSOs, 2014 (Q2) - demand creation meetings in all demand creation meetings at SMoH 2018 (Q3) 11 LGAs. facility and communities: (1) Leverage support by engaging WDCs, VDCs, HFs, 1,188,000 CBOs, FBOs, youth clubs and women groups for mobilizing target audiences in communities. (2) Develop community drama.

38 COSTING OF TIME THE REQUIRED STRATEGIC ACTIVITY IDENTIFIED FRAME RESOURCES INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013‒2018 (NGN) 3.1.4 Engage media outlets to create Create awareness through RH TWG, SMoH and 2013 (Q4) - awareness of FP services. media such as radio, postal, development partners 2018 (Q3) 0 leaflets, billboards. 3.1.5 Engage PHC facilities, NGOs and SMoH, LGA and Partners 2014 (Q2) - CBOs to provide youth friendly 2018 (Q3) services (YFS) and increase 0 access of young people to YFS.

2. Training 3.2.1 Develop/adapt and FP coordinator, state social 2014 (Q2) - and capacity distribute/disseminate IEC/BCC mobilization officers 2018 (Q3) building materials (posters, leaflets and (SSMOs), LGA MCH booklets) and messages (jingles, coordinators 0 TV spots, Bulk SMS, VOX Pop and PSAs) on FP.

3.2.2 Distribute information materials. 2014 (Q2) - 0 2018 (Q3) 3.2.3 Train men-to-men mobilizers as a B4H resource persons, 2014 (Q2) - Brothers for Health (B4H) CS/RH coordinators, media 2018 (Q3) 660,000 initiative and develop action to educate men on their role plans. in child spacing 3.2.4 Train women community Provide BCC materials and S4H resource persons, 2014 (Q2) - mobilizers as a Sisters for Health job aids (motivational flip CS/RH coordinators, media 2018 (Q3) 660,000 (S4H) initiative and develop action charts) to trained MAPs. to educate men on their role plans. in child spacing 3.2.5 Conduct training ARH and YFS for ARH coordinator, state 2014 (Q2) - health personnel at PHCs and training teams, resource 2018 (Q3) 14,340,000 NGO officials persons

39 COSTING OF TIME THE REQUIRED STRATEGIC ACTIVITY IDENTIFIED FRAME RESOURCES INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013‒2018 (NGN) 3.2.6 Support CBOs, CSOs, NGOs to ARH coordinator, state 2014 (Q2) - train in-school and out-of-school master trainers, resource 2018 (Q3) youths on peer health education persons 0 activities.

3.2.7 Provide ARH and YF IEC materials ARH coordinator, state 2014 (Q2) - to trained young people in youth- training teams, resource 2018 (Q3) based CSOs and CBOs. persons 0

3.2.8 Equip trained peer health ARH coordinator, state FP 2014 (Q2) - educators with kits and IEC/BCC coordinators and NGOs, 2018 (Q3) materials for implementation of 66,000 PHED activities and referral.

3. Service 3.3.1 Distribute IEC materials to health FP coordinator, LGA MCH 2014 (Q2) - provision and facilities to facilitate the provision coordinators, HFs 2018 (Q3) of health talks and home visits for supportive 0 supervision counseling at facility and community levels.

3.3.2 Support CBOs to conduct CHEWs, NGOs, CBOs, FBOs 2014 (Q2) - community outreaches, such as and WDCs and QIT 2018 (Q3) house-to-house visits and mobile members 396,000 clinics/caravans targeted at hard- to-reach communities in Gombe state. 3.3.3 Supervise community outreaches LGA, SMoH 2014 (Q2) - and other community-based 2018 (Q3) 0 activities.

40 COSTING OF TIME THE REQUIRED STRATEGIC ACTIVITY IDENTIFIED FRAME RESOURCES INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013‒2018 (NGN) 7. Monitoring 3.7.1 Develop tools to track activities of Review existing community SSMO, FP, ARH 2014 (Q1) MAPs, B4H and S4H at the tools to ensure the inclusion coordinators, FHI and reporting 0 community level (link with FP key of CB distribution of FP message development). services. 3.7.2 Monitor media and community- 2014 (Q2) - based FP activities. 2018 (Q3) 0

3.7.3 Conduct quarterly reviews of daily M&E officer, FP coordinators 2014 (Q2) - registers and daily consumption (state and LGA), director of 2018 (Q3) book. Planning, Research & 0 Statistics, facilities in-charge officers, PHC coordinators 3.7.4 Conduct quarterly reviews of 2014 (Q2) - community mobilization and 2018 (Q3) media outreaches/programming 0 data.

3.7.5 Disseminate semiannual reporting Routine compilation and 2014 (Q2) - of FP use data at LGA, state reporting of service statistics 2018 (Q3) 0 levels. at facility, LGA and state levels. 3.7.6 Integration of data into state 2014 (Q1) HMIS system. 0

3.7.7 Conduct study to document Pre- , mid- and post- RH TWG, M&E TWG, SMoH, 2013 (Q4) attitudes towards FP. intervention RH TWG, SMoH development partners 0 and development partners

3.7.8 Document best practices. 2014 (Q2) - 0 2018 (Q3)

41 COSTING OF TIME THE REQUIRED STRATEGIC ACTIVITY IDENTIFIED FRAME RESOURCES INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013‒2018 (NGN) 8. Integration 3.8.1 Integrate FP messages into MNCH RH TWG, MCH Coalition 2014 (Q2) - of FP with week mobilization activities. 2018 (Q3) 0 HIV/AIDS and MNCH Subtotal 20,210,000 Objective 3

42 4.4 Objective 4

Objective 4: Increase the level of state and community support for FP services in Gombe state by 2018.

• Target 1: At least 70 percent of community leaders permit the implementation of community-based FP in their communities in Gombe state by 2018.

• Target 2: 100 percent of policymakers at the state and LGA levels support implementation of FP programmes in Gombe state by 2018.

COSTING OF TIME REQUIRED STRATEGIC ACTIVITY IDENTIFIED FRAME RESOURCES INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013‒2018 (NGN) 1. Advocacy 4.1.1 Conduct a stakeholder meeting to (1) Pay advocacy visit to Legislators, executives, LGA 2014 (Q1) 0 and social mobilize political will and concerned stakeholders. (2) councils, traditional and mobilization leadership for increased support Send out invitation letters. community leaders, religious for an for access to FP services (link with leaders, opinion leaders, RH other stakeholder engagement TWG, CSOs, CBO enabling efforts). development partners environment

4.1.2 Develop a partnership framework SMoH, LGA, RH TWG 2014 (Q1) 900,000 to strengthen engagement with policymakers, CSOs and community leaders.

4.1.3 Engage with selected CSO and SMoH, LGA, RH TWG 2014 (Q1) - 0 CBOs. 2018 (Q3)

43 COSTING OF TIME REQUIRED STRATEGIC ACTIVITY IDENTIFIED FRAME RESOURCES INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013‒2018 (NGN) 4.1.4 Conduct sensitization meetings for SMoH, LGA SMO, RH TWG 2014 (Q1) - 1,188,000 community gatekeepers. 2018 (Q3)

4.1.5 Support community dialogue SMoH, LGA, RH TWG 2014 (Q1) - 1,188,000 among community members. 2018 (Q3)

4.1.6 Conduct bi-monthly review (1) Identify the participants MCH, FP, ARH & DPHC 2014 (Q2) - 0 meeting with HF in-charges and of the meeting. (2) Prepare 2018 (Q3) LGA MCH coordinators. the meeting logistics. (3) Conduct the meeting. 4.1.7 Conduct advocacy to line Pay solicitation courtesy visits RH TWG 2013 (Q4) - 0 ministries and policymakers. to MoH, Ministry of Women 2018 (Q3) Affairs, LGSC, LGCA, economic and budget planning and house committee on health. 4.1.8 Conduct advocacy and Implement advocacy and RH TWG 2014 (Q1) - 1,188,000 sensitization visits to gatekeepers, sensitization to LG chairmen, 2018 (Q3) traditional and religious leaders traditional leaders and and LGA council members. gatekeepers.

2. Training 4.2.1 Conduct a two-day training on SMoH, LGAs, CSOs and 2014 (Q1) 1,728,000 and capacity advocacy and social mobilization CBOs and 2016 building strategies for CBOs, CSOs and (Q1) SMOs to increase and improve method mix and funding for FP.

4.2.2 Conduct training on interpersonal (1) Identify participants. (2) SMoH, RH TWG, LGA, Q1‒Q4 0 skills and communication for Conduct training. (3) Monitor development partners. CHEWs, nurses and doctors ( link activities post-training. with HW training)

44 COSTING OF TIME REQUIRED STRATEGIC ACTIVITY IDENTIFIED FRAME RESOURCES INTERVENTION CODE ACTIVITIES SUBACTIVITIES STAKEHOLDERS 2013‒2018 (NGN) 7. Monitoring 4.3.1 Conduct a mapping of community (1) Conduct baseline Community leaders, 2013 (Q1) 0 and reporting leaders and policymakers and mapping and assessment of policymakers, LGA their levels of support for FP. level of support of community chairmen/representatives, leaders and policymakers. M&E officers, PHC (2) Implement a post- coordinators, Commissioner intervention survey to for Health, Supervisory document changes In the Councilor for Health, level of support for FP. Permanent Secretary of SMoH, Permanent Secretary of LG & Chieftaincy Affairs, chairman of Local Government Service Commission, development partners 4.3.2 Monitor statements of support or Engage with media, CBOs CSOs, CBOs, Gombe RH 2014 (Q1) - 0 nonsupport for FP by and CSOs to assist in TWG 2018 (Q3) policymakers and community and documentation. religious leaders.

Subtotal Objective 4 6,192,000.00

BUDGET SUMMARY The Gombe State Framework for the Implementation of Expanded Access to Family Planning Services 2013‒2018 has an estimated cost of 1.019 billion Naira over a six year 5 implementation period. The resource requirements for the four objectives by each strategic intervention area are summarized below.

STRATEGIC OBJECTIVE OBJECTIVE INTERVENTION OBJECTIVE 1 OBJECTIVE 2 3 4 SUBTOTAL Advocacy and social 540,000 1,585,000 4,088,000 4,464,000 10,677,000 mobilization to create an enabling environment for FP

Training and 55,461,000 648,000 15,726,000 1,728,000 73,563,000 capacity building Service provision 62,320,000 21,816,000 396,000 0 84,532,000 and supportive supervision Quality assurance 49,850,000 4,620,000 0 0 54,470,000

Commodities and 286,626,000 502,750,000 0 0 789,376,000 logistics Finance and 0 0 0 0 0 resources Monitoring and 3,415,000 2,397,600 0 0 5,812,600 reporting Integration of FP 0 1,200,000 0 0 1,200,000 with HIV/AIDS and MNCH

TOTAL (naira) 458,212,000 535,016,600 20,210,000 6,192,000 1,019,630,600

APPENDIX 1. CALCULATION JUSTIFICATIONS AND ASSUMPTIONS This appendix provides the calculations and assumptions that support the goal, objectives and annual projections made throughout this framework. These calculations and assumptions were developed under the guidance of the Gombe RH TWG with technical assistance from a health economist and the assumptions were based on state-specific and national reports as well information acquired from Gombe state health officials and stakeholders.

Table A1.1. Number of Health Personnel Providing FP and Training in FP

ADDED BASICS INJECTABLE CPR CHEWS CLINICIAN OF FP PROVISION YEAR (%) CHEWS PER YEAR LOE TRAINING TRAINING 2012 8.82 1,652 n/a 13.4% n/a n/a

2013 9.90 1,707 55 8.7% $ 35,000 $ 16,000 30% trained 2014 11.62 1,762 55 3.2% $ 42,000 $ 19,000 60% trained 2015 13.64 1,817 55 0.5% $ 66,000 $ 30,000 100% trained 2016 16.02 1,872 55 0.6% $ 22,000 $ 10,000 100% trained 2017 18.81 1,927 55 4.3% $ 25,000 $ 11,000 100% trained 2018 22.10 1,982 55 10.7% $ 28,000 $ 13,000 100% trained

Assumptions: The 2012 baseline begins with the current projected CPR and number of health workers available. 5 CHEWs (including JCHEWs) will spend 20 percent (or 8 hours) of their effort delivering FP services including condoms, pills and injectables. An additional 55 CHEWs graduating from the state’s school of health technology will be hired by the SMOH and trained on cadre-specific methods. Clinicians’ (including doctors, nurses and midwives) level of effort (LOE) for providing FP services is estimated based upon two factors. First, the use of LAPMs (implants and IUDs) that only these cadres of health workers can provide and second, as well as the remaining work load for providing condoms, pills and injectables that the CHEWs are unable to support. Regarding training, the 2012 estimate assumes only 5 percent of CHEWs have been comprehensively trained in FP service provision. Trainings assume cadres of 40 trainees and that each year 10 percent of prior trainees will require retraining (primarily due to health worker turnover). Cost estimates are based on basic FP training and injectables-specific training expenses incurred during the pilot study.1

47 Table A1.2. Clinicians Required by Base Year

YEAR NURSES/MIDWIVES DOCTORS TOTAL 2012 140 61 201 2013 140 61 201 2014 140 61 201 2015 140 61 201 2016 140 61 201 2017 140 61 201 2018 140 61 201

Assumptions: A total of 201 clinicians5 (including nurse/midwives and doctors) are targeted for increasing the provision of LAPMs as this is the estimated number of providers who work in maternity clinics (i.e. antenatal care, labour, postnatal care and family planning) which are patronized by women and children and provide the vast majority of FP services. These calculations assume that each clinician can accommodate one LAPM (implants and IUDs) insertion per month and, therefore, that no additional providers will be required until insertion volume passes 2,400 per year. While the focus is on insertions, the percent change from clinicians in 2012 assumes removals of the LAPMs were also included in workloads. The number of clinicians does not change year to year because this is based upon staffing quotas and a fixed number of service points or facilities.

Table A1.3. Number of Wards with Access to CBFP and Health Facilities Providing FP CPR COMMUNITIES (I.E. SECONDARY AND YEAR (%) WARDS) PHC TERTIARY 2012 8.82 9% (10) 20% (101) 12.5% (2)

2013 9.90 30% (35) 30% (152) 30% (5) 30% trained 2014 11.62 60% (69) 60% (303) 60% (10) 60% trained 2015 13.64 100% (114) 100% (505) 100% (16) 100% trained 2016 16.02 100% (114 100% (505) 100% (16) 100% trained 2017 18.81 100% (114) 100% (505) 100% (16) 100% trained 2018 22.10 100% (114) 100% (505) 100% (16) 100% trained Assumptions: Gombe’s 11 LGAs are further divided into 114 wards which represent communities or neighborhoods.5 To reach the CPR targets wards must be provided with CBFP by CHEWs. The wards’ access to FP (including injectables) will increase as more CHEWs are trained in CBFP and then maintained. The 2012 baseline for wards’ access to FP only reflects the 10 wards that participated in the CBA2I pilot because others wards receiving outreach from the PHCs were only provided with condoms and pills but not injectables. 1,9 Similarly, the PHCs’ and secondary/tertiary facilities’ coverage of FP service provision will incrementally increase as more CHEWs, nurses/midwives and doctors are trained to provide cadre-appropriate methods.

Table A1.4. Requirements to Reach CPR Goal — Number of FP Users, Number of Commodities, Cost for Commodities and Logistics, Percent of Users by Method

2012 2013 2014 2015 2016 2017 2018 TOTAL CPR (%) 8.82 9.90 11.62 13.64 16.02. 18.81 22.10 Condoms Users 657 948 1,372 1,931 2,336 2,826 3,420 13,489 Commodities 73,610 106,141 153,638 216,233 261,638 316,487 383,077 1,510,824 Price (naira) 549,868 792,869 1,147,679 1,615,257 1,954,435 2,364,158 2,861,582 11,285,851

Users by method 1.7 2.1 2.6 3.0 3.0 3.0 3.0 N/A (%) Pills Users 6,438 6,733 7,284 7,776 9,013 10,426 12,045 59,715 Commodities 31,334 32,765 35,447 37,844 43,864 50,740 58,621 290,615 Price (naira) 846,005 884,663 957,068 1,021,795 1,184,325 1,369,972 1,582,778 7,846,609 Users by method 16.7 15.1 13.6 12.0 11.5 11.1 10.6 N/A (%) Injectables Users 30,590 35,539 43,173 52,449 63,485 76,822 93,018 395,078 Commodities 148,873 172,958 210,111 255,253 308,963 373,866 452,688 1,922,711 Price (naira) 28,806,9 33,467,404 40,656,427 49,391,492 59,784,266 72,342,977 87,595,067 372,044,589 53 Users by method 79.3 79.9 80.5 81.0 81.3 81.5 81.7 N/A (%) Implants Users 657 948 1,372 1,319 2,404 2,990 3,718 14,019

49 2012 2013 2014 2015 2016 2017 2018 TOTAL Commodities 398 509 740 1,010 1,071 1,329 1,652 6,711 Price (naira) 1,544,88 1,974,921 2,870,630 3,916,422 4,152,196 5,154,546 6,406,731 26,020,333 3 Users by method 1.7 2.1 2.6 3.0 3.1 3.2 3.3 N/A (%) IUDs Users 219 316 457 644 892 1,216 1,636 5,379 Commodities 120 149 217 294 398 529 698 2,406

Price (naira) 18,947 23,519 34,223 46,305 62,762 83,297 109,861 378,971 Users by method 0.6 0.7 0.9 1.0 1.1 1.3 1.4 N/A (%) Total users, all 38,562 44,483 53,658 64,730 78,131 94,279 113,837 FP methods

Assumptions: To meet the incrementally increasing CPR target each year, the number of FP users, number of commodities, cost for commodities and logistics will also increase. The estimates for users by method are based on the formula: contraceptive prevalence × population. 2,3 An annual % increase in # users ranges from 15.4% to 20.7% with an average annual increase of 19.8% from 2012 -2018.

The estimates for commodities by method are based on the formula: number of users × volume of commodities per user per year × 1.12 This formula also allows for 12% wastage. And the volume of commodities per user by method are: For condoms, assume 100/user/year; For pills and injectables, assume 4.35 units/user/year; For implants, assume 0.25 units/prior user/year (average expected use = 4/year) plus one unit for each new user; for IUDs, assume one-sixth unit for prior users (average expected use = 6/year) plus one unit for each new user.

The price for the commodities by method is described below in Table A1.5.

Additionally, the percent of users by method is provided to illustrate the changes in the method mix.

Table A1.5. Commodity Costs (US$)

COMMODITY LOGISTICS TOTAL

Condoms 4.15 0.83 $4.98 $ per 100 condoms

Injectables 1.08 0.22 $1.29 $ per vial

IUD 0.87 0.17 $1.05 $ per unit

Implants 21.54 4.31 $25.85 $ per unit Pills 0.15 0.03 $0.18 $ per pack

Assumptions: These costs are based on international prices.13 The logistic expenses are estimated at 20 percent of the cost of the commodity.

Table A1.6. FP Support by Men, Women, Youth, Community Leaders and Policymakers

MEN, WOMEN, YOUTH (% YEAR INCREASE) COMMUNITY LEADERS (%) POLICYMAKERS (%)

2012 0 10 10 2013 5 25 25 2014 10 30 40 2015 20 40 55 2016 30 50 70 2017 40 60 85 2018 50 70 100

Assumptions: State health officials and stakeholders concluded that among men, women and youth of reproductive age, support for FP needed to increase and could be accomplished through FP education CHEWs will provide as part of their extension services and broader community-level advocacy initiatives that are planned. The baseline for FP support is unknown but perceived to be low given the state’s low unmet need for FP (13.2%) and other FP indices.2

The majority of community leaders’ (ward heads, religious leaders) and all policymakers at the state and LGA-levels (emirs, commissioners and permanent secretaries) will need to support FP as demonstrated by their participation in FP expansion planning meetings and the absence of clear opposition to advancing FP efforts.

Table A1.7. Family Planning Impact Indicators

DISABILITY- INFANT UNDER-5 MATERNAL ADJUSTED LIFE CPR PREGNANCIES BIRTHS MORTALITIES MORTALITIES MORTALITIES ABORTIONS YEARS (DALYS) YEAR (%) CYP AVERTED AVERTED AVERTED AVERTED AVERTED AVERTED AVERTED 2012 baseline 8.82 41,470 23,697 17,232 1,675 3,253 190 4,329 10,227

2013 9.90 48,269 27,582 20,057 1,950 3,787 221 5,039 11,904 2014 11.62 59,022 33,727 24,526 2,384 4,630 270 6,161 14,556

2015 13.64 72,016 41,152 29,925 2,909 5,650 329 7,517 17,760

2016 16.02 86,855 49,632 36,092 3,508 6,814 397 9,066 21,420

2017 18.81 105,243 60,139 43,732 4,251 8,257 481 10,986 25,955

2018 22.10 127,612 72,921 53,028 5,154 10,012 583 13,321 31,471

Total N/A 540,486 308,849 224,593 21,830 42,403 2,471 56,419 133,292

Assumptions: The couple years of protection (CYPs) based upon the latest USAID conversion factors 14 and estimated protection provided by contraceptive methods during a one-year period, based upon the volume of all contraceptives sold or distributed free of charge to clients during that period.

The conversions coefficients for the other indicators are measured per CYP for Nigeria 15 include: number of pregnancies averted 0.571429, number of births averted 0.415539, number of infant mortalities averted 0.040390, number of under-5 mortalities averted 0.078454, number of maternal mortalities averted 0.004571, number of abortions 0.104386 and DALYs 0.246616.

APPENDIX 2. SUMMARY OF STAKEHOLDER ANALYSIS This appendix summarizes a rapid assessment conducted in Gombe in 2012 to understand state, LGA and community-level stakeholders’ knowledge, support and ability to advance FP efforts. The assessment was conducted by staff from FHI 360 with approval and guidance from the SMoH.

STAKEHOLDER GROUP STAKEHOLDER TITLE STAKEHOLDER CHARACTERISTICS6 OUTCOMES

Knowledge Position Interest Resources Alliance Power Leadership

Govt. Ministries Minister of Health High Supportive High High High High High Policy change allowing CHEWs to provide injectable contraceptives in communities FMoH Director, Family Health Department RH Coordinator SMoH Commissioner of Health High Supportive High High High High High Mandated and supported the RH TWG to hold meetings and panel discussions to develop the Permanent Secretary framework Director PHC SMoLGA Commissioner of Health Medium Supportive High High High High High Participated in developing the framework.

6 Definitions of stakeholder characteristics assessed:

Knowledge: Level of understanding of FP. This was rated as high, medium or low. Position: Support or opposition to FP. This was rated as support or oppose Interest: Level of importance given to FP to improve maternal and child health. This was rated as high, medium or low. Alliance: Access to groups that can influence FP. This was rated as high, medium or low. Resources: Access to personnel and funds that can be used to influence FP. This was rated as high, medium or low. Power: Ability to use their resources and alliances to influence CBA. This was rated as high, medium or low. Leadership: Willingness to use their resources and alliances to support CBA. This was rated as high, medium or low.

STAKEHOLDER GROUP STAKEHOLDER TITLE STAKEHOLDER CHARACTERISTICS6 OUTCOMES

Knowledge Position Interest Resources Alliance Power Leadership

Permanent Secretary Will support logistics and distribution of RH commodities State PHC Coordinator

SMWASD Commissioner of SWASD High Supportive High High High High High Participated in the RH TWG meetings for developing the framework Permanent Secretary Director, Women Affairs Will support FP community mobilization

Community Mobilization Officer SMoEP Commissioner High Supportive High High High High High Participated in the RH TWG meetings for Permanent Secretary developing the framework Will support inclusion of the framework in the Director of Planning state budget Local Executive Director High Supportive High High High High High Participated in the RH TWG meetings for Government Director PHC developing the framework. Service Committed to providing health workforce Commission required to scale up community-based FP Community Emir of Kaltungo High Supportive High High High High High Committed to support community mobilization Leaders Emir of Yamaltu activities to promote FP Emir of Deba Emir of Dukku Implementing SFH High Supportive High High High High High Participated in developing the framework Partners NURHI TSHIP Will support programme implementation of the UNICEF framework WHO UNFPA

STAKEHOLDER GROUP STAKEHOLDER TITLE STAKEHOLDER CHARACTERISTICS6 OUTCOMES

Knowledge Position Interest Resources Alliance Power Leadership Donors USAID High Supportive High High High High High Funded efforts for policy change allowing CHEWs to provide community-based FP; funded the development of Gombe state’s framework for expanding access to FP

APPENDIX 3. PARTICIPATION LIST: CBA TWG MEETING CONVENED SEPTEMBER 21 22, 2011, ON THE ROAD MAP FOR SCALING UP COMMUNITY-BASED ACCESS TO ‒ FAMILY PLANNING FOCUSED ON INJECTABLES IN NIGERIA

Venue Vines Hotel, Durumi Abuja

Chair Prof. Oladapo A. Ladipo — CEO Association for Reproductive and Family Health

FMoH P. N. Momah — Head Family Health Department Abosede Adeniran — Head Reproductive Health Division Nneka Nkem Oteka — National FP Coordinator Yemisi Akinkumi — National Programme Officer Manuel Oyinbo J. U. Ononose Ralph Olayele Pharm Alex Ugochukwu Mrs. Bamigbe Osuntogun Adesola Adesanwo Omolola Oluyomi Oluwayomi Ale Temitope Bombata National Primary Health Care Development Agency Dr. Nnenna Ihebuzor — Director, Community Health Services Dr. David Malgwi Pabar Dr. Theodore Madike

Regulatory Bodies Community Health Practitioner’s Registration Board of Nigeria Mr. Shiono Bennibor — Registrar

Nursing and Midwifery Council of Nigeria Mr. Olaniyi Filade States Rejoice Bala — Gombe State FP Coordinator

Donor Agencies United States Agency for International Development (USAID) Folake Olayinka Kayode Morenikeji

United Nations Population Fund (UNFPA) Nasser Elkholy Adeola Olunloyo

Implementing Partners Advocacy Nigeria Chinyere Ikenna Ummulkhair Usman

FHI 360 Kwasi Torpey Hadiza Khamofu Lilian Anomnachi Zubaida Abubakar Michael Odo Ignatius Mogaba Rabiatu Hadi Mariya Saleh Tracy Orr Laide Shokunbi Ginikanwa Amauche Mafo Yakubu

JH PIEGO Lydia Airede

Planned Parenthood Federation of Nigeria Ibrahim M. Ibrahim Uduak George

Society for Family Health Bartholomew Odio

TSHIP Janet Ibinola Julian Nathaniel Hajiya Fatima Inuwa

APPENDIX 4. PARTICIPATION LIST: PLANNING MEETING CONVENED JULY 18 20, 2012, ON THE GOMBE STATE FRAMEWORK FOR THE ‒ IMPLEMENTATION OF EXPANDED ACCESS TO FAMILY PLANNING SERVICES FRAMEWORK 2013 2018 Consultants Nnenna Mba-Oduwusi ‒ Olayiwola Ogunjobi

FMoH Dr. Bridget Okoeguale Dr. Kayode Afolabi

Nursing and Midwifery Council of Nigeria Mr. Olaniyi Filade Gombe State Reproductive Health Technical Working Group Gombe SMoH Nuhu Kumangh — Director Primary Health Care, Gombe SMoH Ibrahim Hassan Abdu Abubakar — Deputy Director Primary Health Care Rejoice Bala — FP Coordinator Maryam Abubakar — Reproductive Health Coordinator Hauwa Lauco — Adolescent Health and Development Aishatu Haruna — Safe Motherhood Coordinator Esther Tinjja Gabakau — Maternal and Child Health Coordinator, Funakaye LGA Ahmed Maikano Bello — Social Mobilization Officer, Funakaye LGA Ramatu Aliyu Kunde — Service Provider, Hashidu PHC Funakaye LGA

Other Line Ministries Adamu Puma Mamman — Ministry of Women Affairs and Social Development, Gombe State Stephen Nabuni Ayuba — Ministry of Economic Planning, Gombe State

Partners FHI 360 Hadiza Khamofu Mariya Saleh Bridget Nwagbara Muhammad Muhammad Saleh

Nigerian Urban Reproductive Health Initiative Fatima Bunza

TSHIP Julian Nathaniel Hajiya Fatima Inuwa

58 APPENDIX 5. PARTICIPATION LIST: REVIEW MEETING HELD OCTOBER 4, 2012, ON THE GOMBE STATE FRAMEWORK FOR THE IMPLEMENTATION OF EXPANDED ACCESS TO FAMILY PLANNING SERVICES FRAMEWORK 2013 2018

Gombe State RH Technical Working Group Alh Umaru Gurama — Permanent Secretary,‒ SMoH Dr Nuhu Kumangh — Director, PHC Abdu Abubakar — Deputy PHC Coordinator, SMoH Ibrahim Hassan — State AIDS Control Programme Coordinator Rejoice Bala Aliyu — FP Coordinator, SMoH Hauwa Lauco — Adolescent Coordinator, SMoH Aishatu Haruna — MNCH Coordinator, SMoH Amina Nuhu K. — Deputy MNCH Coordinator, SMoH Maryam Abubakar — RH Coordinator, SMoH Hassana Shegeth — FP Champion

Expanded RH TWG Aishatu Ahmed — CNO, MCH Coordinator, Gombe LGA Marina Bappa — MCH Coordinator, Shongom LGA Nwese Apu — MCH Coordinator, Nafada LGA Dija Ahmed — MCH Coordinator, Kwami LGA Lewi Patriacia — MCH Coordinator, Billiri LGA Aliyu Aishatu Adamu — MCH Coordinator, Dukku LGA Yerima Comfort — MCH Coordinator, Y/Deba LGA Ahmed Maikano — SMO, Funakaye LGA Mary Sadi — CNO/APHCC-MCH, Akko LGA Ajuji Bulus — MCH Coordinator, Kaltungo LGA Subi Chapeh — MCH Coordinator, Balanga LGA Esther Tinja — DPHC Coordinator, Funakaye LGA Mairo Maigana — MCH Coordinator, Funakaye LGA Aliyu Kunde Ramatu — CHEW representative, Funakaye LGA Adamu Mamman Puma — Ministry of Women Affairs and Social Development, Gombe State

Regulatory and Professional Bodies Community Health Practitioners Registration Board Abubakar Wuda Goni — CHPRBN, North East

Society of Obstetricians and Gynaecologists Melah G. Sule — Consultant, SOGON

Civil Society Representatives Abubakar Hassan — MCH Coalition

59 Partners Mamman Sulaiman — UNICEF Assistant Coordinator Maikano Paul .Y. — WHO, SE/LGF Bathsheba Jonah Kalah — PPFN State Coordinator

FHI 360 Mansa Musa Adamu — SPC, Gombe Muhammad Muhammad Saleh Mariya Saleh Bridget Nwagbara Joy Hadiza Marcus Joshua O.

Consultants Nnenna Mba-Oduwusi Olayiwola Ogunjobi

60 APPENDIX 6. WHO HEALTH SYSTEM FRAMEWORK

Source: WHO, 20078

WHO defines the performance of each building block as follows:

1. Service delivery: “Effective, safe, quality personal and impersonal health interventions” delivered to those who need them, when and where they are needed.

2. Health workforce: Personnel who are competent, responsive, fair, and efficient and who are equitably deployed in numbers and capacities sufficient to the need.

3. Information: A system that ensures the production, analysis, dissemination, and use of reliable and timely information about health determinants, health system performance, and health status.

4. Medical products, vaccines, and technologies: Products of assured quality, safety, efficacy, and cost-effectiveness.

5. Financing: A system with adequate financial resources for health such that people can access the services they need without fear of financial catastrophe or poverty associated with having to pay for medical services.

6. Leadership and governance: Strategic policies and frameworks existing in combination with oversight, regulation and accountability.

REFERENCES

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13. Management Science for Health (MSH). International drug price indicators, 2011 [Internet]. Cambridge, MA (USA): Management Science for Health; 2012. Available from: http://erc.msh.org/dmpguide/pdf/DrugPriceGuide_2011_en.pdf

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OTHER RESOURCES Federal Ministry of Health (Nigeria). Strategic plan for reproductive health commodity security 2011– 2015. Abuja (Nigeria): Federal Ministry of Health; 2011.

Singh S. and Darroch, J.E. Adding it up: Costs and benefits of contraceptive services, estimates for 2012 [Internet]. United National Population Fund (UNFPA). 2012 June. Avaiable from: http://www.guttmacher.org/pubs/AIU-2012-estimates.pdf